Basic Information
| Provider Information | |||||||||
| NPI: | 1205898715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 E CAMELBACK RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022649100 | ||||||||
| FaxNumber: | 6022649101 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 W BASELINE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852106047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804611088 | ||||||||
| FaxNumber: | 4804611657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3166 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.